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Quote
Company Name:
Company name
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Legal Tax Class
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C-Corp
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LLC or LLP
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Non-Profit 501(c)(3)
Other / I don't know
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Company EIN:
Tax ID for the company
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Number of Employees:
Total full time employee headcount
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Company Address:
Company's Legal Address
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City:
City
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State:
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Zip Code:
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Your Name:
Your Name
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Your Email Address:
Your E-mail Address
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Your Phone Number:
Your Phone Number
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Kind of Quote Requested
Health Insurance
Dental Insurance
Disability Insurance
401K Plan
Payroll or HR Services
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Does the Company have a GROUP health plan right now?
Yes
No
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Current GROUP Health Insurance Carrier:
Name of health insurance company
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[{"field":"current_health_plan","logic":"equal","value":"yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
Name(s) of Health Plans Offered:
Name of the insurance plan people enroll into
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[{"field":"{current_health_plan}","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
Amount Company Pays Towards Health Insurance:
This is usually a flat dollar amount or percentage of premium
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[{"field":"current_health_plan","logic":"equal","value":"Yes","and_method":"","field_and":"","logic_and":"","value_and":""}]
[{"field":"{quote}","logic":"contains","value":"Health Insurance","and_method":"","field_and":"","logic_and":"","value_and":""}]
Does the Company have a GROUP disability plan right now?
Yes
No
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Will Company pay towards disability coverage?
Yes
No
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Census Instructions:
Please upload a document with each employee's date of birth (or age), gender, tobacco smoking status (i.e. do they smoke?), home zip code, and estimated annual salary
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Census Upload
Upload your documents...
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[{"field":"{quote}","logic":"contains","value":"Disability Insurance","and_method":"","field_and":"","logic_and":"","value_and":""}]
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